Community Involvement in Indonesia

27 November 2006

Dr Delyuzar,Medan

The STOP TB StrategyThe STOP TB Strategy

Component 5:

Empower people with TB and communities

5yr Strategic Plan to Control TB5yr Strategic Plan to Control TBin Indonesia 2006in Indonesia 2006--20102010

EXPANSION of TB CONTROL1. Pursue quality DOTS expansion and

enhancement2. Address TB/HIV, MDR-TB and other

challenges3. Involve all care providers4. Engage TB patients and affected

communities

Supported by Health System Strengthening:5. Strengthened policy and ownership6. Strengthened health system and TB control

management7. Research

What is Community TB Care (CTBC)What is Community TB Care (CTBC)

Operational partnership between the health services and civil society (motivated individuals, existing community volunteers, etc.) aimed at contributing to TB care.

Support to patients (DOT) throughout treatment

Bringing services closer to patients (sputum collection)

Patient, family and community education

Case detection (referral of pts with chronic cough)

Advocacy for political commitment to TB control

Health promotion (creating demand for services in society)

Community Challenges in Indonesia

• Access to healthcare (private, remote)• Cost-barriers (transport, userfees)• Low local political commitment to health• Lack of partnerships at local level• Low level of involvement of (ex) TB

patients• Health care seeking patters differ across

country

Initiation of treatment

0%

10%

20%

30%

40%

50%

60%

SUMATRA KTI JAVA

Initiation of treatmentHospital & BP4Initiation of treatmentPrimary Health CareInitiation of treatment PrivatePracticioners

Treatment seeking practices in patients with hx of TB (Prevalence survey 2004)

Ending of treatment

0%

10%

20%

30%

40%

50%

60%

70%

SUMATRA KTI JAVA

Ending of treatment Hospital& BP4Ending of treatment PrimaryHealth CareEnding of treatment Private Practicioners

TB Community models

1. Sub healthcentre/ TB posts (mobile) linked to health centre with TB program

2. Community members linked to health centre TB program

3. Urban health centre managed by NGOs/ faith-based networks

Family/ Clan leaders (‘Ninik Mamak’)Indonesia, West-Sumatra

• Clan-leaders identify, support, accompany and refer suspects to health centre (referral form), and become support to daily treatment supporter (PMO) who is family member

• Standardized referral sheets are used by Health centre for the suspect identification. This adds to:1. Professionalize referral from community

groups2. Account and validate community contribution3. Encourage positive contributions

Effectiveness of Ninik Mamak involvementat Kampung Dalam Health Center, Padang Pariaman – West Sumatra

Support from Ninik Mamak: • Increase of TB suspect thanks to Ninik Mamak (54%: 2005 and 38%: Q1 2006)• Proportion of Sm+ among suspect examined > 10% identify TB patient• TB knowledge increased people come themselves

0

144

4216

179

266

3618 10

0

50

100

150

200

250

300

Suspect (refered by NinikMamak)Suspect Total

Sm (+)

Suspect (refered byNinik Mamak)

0 144 16

Suspect Total 179 266 42

Sm (+) 18 36 10

2004 2005 2006 (Q1)

Indonesia: Active community participation

0

20

40

60

80

100

120

140

160

180

1996 1997 1998

CNR - CTBCNR - non CTBSR - CTBSR - non CTB

Family members as DOTS Family members as DOTS treatment observerstreatment observers

Central Central SulawesiSulawesi 19961996--19981998• TB case notification increases in

a community based tuberculosis program (CBTP)

• Results before and after introduction of the program

• Comparison with area where the program was and was not introduced.

• Maintain high treatment success rates and sputum conversion rates

M. Becx-Bleumink, H. Wibowo, W. Apriani, H. Vrakking, INT J TUBERC LUNG DIS 5(10):920–925 © 2001 IUATLD

TB PROGRAMJARINGAN KESEJAHTERAAN/ KESEHATAN

MASYARAKATJL. WILLIEM ISKANDAR NO. 107 B

Phone: (061) 77817575 – 4576350, Fax. (061) 4576350Email: jkm_mdn@yahoo.com

Tackling TB in 7 districts in North Sumatra Province, Indonesia

Phase I performance (First Year):

• 2 interventions – five new microscopy

centers and 21 satellite clinics,

– training community volunteers to enhance suspect identification and case holding.

• Facilitate inaccessible populations in remote areas

Socialization & set-up

• 5 districts mobilize the Provincial Health Authorities and Municipal Health Authorities

• Selection and recruit of staffs and Health Cadres (HCs)

• Preparation of project (laboratory and health service)

• Method of training, orienting the staffs in technical work, and operational standard procedure

Community volunteers

• From permanent resident in target areas

• Motivated to care for TB control, and cure patient and their family.

• An initial 500 community volunteers were trained to increase community awareness, and assist with case holding.

• Of 500 community volunteers initially trained, 360 remained active during the project.

Training Curriculum

• Communication skills • TB Basic Science-

epidemiology• Health Promotion• Collecting sputum &

Case Holding

Phase II activities (Second year):

• 3 Interventions:1. Community

empowerment through existence of health cadres/ volunteers;

2. develop two mobile clinics unit;

3. setting up two new microscopy centers in one new district.

• Health promotion Materials • Radio broadcast (52 times in

a year)• Newspapers advertisement

(everyday during the project life)

• Leaflets

Health promotion

Mobile clinics

• Two mobile clinics unit to cover more remote areas.

• Mobile clinic visit suspect’s house and patient’s house, with smear preparer and TB medicine. (collect sputum, sputum fixation of slide, case holding activities).

• Achieved 60% increase of category of limited access from those specific areas in phase II

Results• 7 additional diagnostic

centres,• New staff working:

– 7 doctors– 14 nurses– 7 lab technicians– 29 smear preparers– 440 volunteers

• Quaterly meetings• 5322 cases detected

(between July 2004 and June 2005)

• 54% increase of the previous year

Thank you